Sunday, 5 February 2012

Dermatology

Hi,

This week, seeing as I have finished my neurology rotation, I move onto dermatology. This has never really been a subject that has interested me all that much, and what I have seen so far this week really just re-affirms this feeling. While dermatology is clearly a valuable subject, with skin conditions being one of the more obvious illnesses, (what with your skin being on the outside of your body, meaning that people can be very upset by such visible problems), it just seems overly complicated to me. Most conditions seem to be treated by either emollients (moisturisers); topical steroids or by cutting bits of skin off. Don't get me wrong, there are other, more complex treatments, but these seem to be in the minority. Dermatologists seem to have made up for this dearth of treatments by creating lots of complicated names for different skin rashes or spots; names which are derived from dead languages. This sounds like I am being scathing of dermatologists, but this isn't the case. Some skin conditions can be very disfiguring, changing peoples lives completely (such as psoriasis), and can be treated effectively, putting peoples lives back to normal. It is a valuable speciality (obviously, just like all the others), but just not a speciality that seems to appeal to me. People don't tend to have emergencies with their skin, meaning you rarely need to treat them immediately for fear of death (quite an exciting idea in medicine for me), though for some people this aspect of dermatology would probably be a real plus (sociable hours!)

All hospital specialities are just as important as one another.

Anyway, perhaps I am judging dermatology too fast, and based on too little information given it is only my first week of the rotation. This week the highlight, if it can be called that, of my time in dermatology was spending a day in the theatre. I went to the dermatology theatres with another medical student, and as there were two lists running we ended up splitting up. One was run by a dermatologist, while the other was being run my a maxillofacial surgeon. Maxfax surgeons need to have both a medical and a dentistry degree (so much time in uni!), and concentrate on the head area of the patient. Neither of us had seen any of this sort of surgery before, whereas we have both seen some dermatology-based-surgery before from placements in first and second years. They only wanted one medical student to be in each theatre, and as surgery and dermatology don't really interest me all that much, I let the other student go in with the Maxfax surgeon, and took the dermatology list.

At the time, this seemed a bit of a mistake, as the dermatologist's list turned out to be super boring. I saw about 8 patients, all of whom had a Basal-cell carcinoma (BCC) or two being removed from their skin. A boring operation, where the cancer is cut out of the skin using an ellipse shape and local anaesthetic, then the skin is stitched up again. BCCs are a common skin cancer, but rarely spread out of the skin, and rarely kill people. It should still be removed though, to stop it growing further, and that was what was being done here. I had already seen this operation in my first year, and all the operations I saw today looked pretty much the same as the operation I saw then. Watching this go on all day was really quite boring, though I am sure that doing the surgeries would be just as boring as well. Another reason not to be a dermatologist! The only real interesting thing which happened during this day of surgeries was meeting a man who used to work in nuclear testing with the British government, and who had kept developing a large number of BCCs all over his body for the last 30 years or so. He had been having 5-10 removed from his body every year for these last 30 years, and it was thought that this was due to the high levels of radiation he may have been exposed to earlier in his life. Developing this large number of BCCs is certainly unusual, and as they are often caused by sun exposure, I don't see why radiation from another source wouldn't cause them as well. Despite this obviously occupational injury, and the inconvenience he has having to go to hospital several times a year to have them cut out, he has no interest in trying to seek compensation at all. He thinks the money is much better off with the government than with him, and he is probably right, though it is a shame more people don't share this sort of mentality. Fortunately (or perhaps, unfortunately) it transpired that the maxfax surgeon's list was exactly the same as the one I sat in on, just removing BCCs from the face, so I didn't really miss anything by my misguided act of kindness.

An image of a basal cell carcinoma from the internet, characterised by its 'pearly coloured' appearance, and raised rounded edges.

Like the previous rotation, dermatology also includes a large number of seminars and lecture-like teaching. More time that I would prefer to spend in clinical teaching, but also more time where I get spoon-fed information, which is always nice. This weeks most notable was a lecture on topical therapies for skin care. The subject material wasn't that exceptional, mostly teaching about emollients and steroid creams, but the nurse leading the seminar had bought along 20-30 different creams for us to try out. Fantastic! I wanted a bit of all of them, so now, if I did actually have any possible infections / autoimmune disorders or any other conceivable dermatological disorder I am now hopefully cured. Cured problems or not, my arms are now certainly highly moisturised!

I also spent some more time on my GP placement again this week, and saw more adults and children with physical and mental illnesses (GPs do see a wide range of problems!). All the time I have been spending with this GP has attracted me more towards being a GP... It still doesn't appeal that much, and I still think I want to follow a different career path into hospital medicine, but my time with the GP has shown me that it really can be fun as well. Before, I just saw it as time which was spent looking after people with snivels and colds, like I found the outpatient department to be like during my time in Tanzania, but there is so much more to it than that. The GP has to make some quite hard calls without any specialist knowledge. For example, a mother came in to see us concerned about her child, who she didn't bring with her as he was at school. She had been concerned about him for some time, and at 4 he still couldn't pick up things like a pen or a knife and fork, and still had no concept of potty training at all. Despite these problems, he can still talk in huge detail about several of his toys, down to the date that he got it. This lack of fine motor skill and problems in learning what the potty was for had worried the mother slightly, as they were very different to her previous child, but she came to the doctor after the teachers at school had told her that they had noticed obsessive traits in his dealings with other children and toys in the class room. Hopefully this is nothing, but these sort of traits could well be suggestive of a problem such as autism. The GP's problem is what to say to the mum, and what plans to make next. She could tell the mum that is was possible that the child had a learning difficulty, and refer them onto a specialist to help the mum cope and investigate the girls behaviour better. This may help the child get help (which they may need), but would this end up putting a label on a child who could otherwise be fine? Or does the GP leave it, and risk the child falling behind in school because they are finding the work much more difficult than the other children? Being a GP seems to involve a lot of 'grey area' sort of decisions that you need to make on your own in a 5 minute space. In this case the possibility of a condition causing this behaviour was discussed with the woman, which was something she already suspected (hence the attendance at the doctor's) and the GP and mother decided together to leave it for now, and see if the difficulties continued; if they did then they could look into getting some extra help for the child. This was pretty much exactly the outcome we are taught towards in medical school - one that is patient choice directed!